Healthcare Provider Details

I. General information

NPI: 1750356663
Provider Name (Legal Business Name): BRADLEY D. CONNETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 NICHOLS RD
OSAGE BEACH MO
65065-3093
US

IV. Provider business mailing address

1075 NICHOLS RD
OSAGE BEACH MO
65065-3093
US

V. Phone/Fax

Practice location:
  • Phone: 573-302-3111
  • Fax: 573-302-2869
Mailing address:
  • Phone: 573-302-3111
  • Fax: 573-302-2869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number102732
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number0424419
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number26727
License Number StateKY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier340017670
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 2
Identifier100153430B
Identifier TypeMEDICAID
Identifier StateKS
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: